Health inspection·May 16, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 1 of 3 residents (Resident #1) reviewed for neglect, in that: The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required reporting timeframes. This failure placed residents at risk ongoing neglect. Findings included: Record review of Resident #1 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Acute Hairline Fracture at Distal radius epi Metaphysis of Left Wrist (Bone Fracture and injury to the growth plate at the wrist end of the radius bone on the forearm); Acute Hairline Fracture at Ulnar Styloid Process (a break in the bony part of the wrist at the end of the ulna(a long bone in the forearm that runs from the elbow to the wrist on the same side the little finger), next to the pinky finger): Peripheral (Vascular) Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Atherosclerosis of Native Arteries of Extremities with Rest Pain, Right Leg (a disease that causes the arteries in the legs and feet to narrow and harden, reducing blood flow). Record review of Resident #1's MDS (Minimum Data Sheet) dated 02/20/2024 revealed Resident #1 BIMS (Brief Interview for Mental Status) score was noted to be 05/15 indicating severe cognitive impairment. Resident #1 required modified to total assistance making decisions regarding tasks and providing daily care. Record review or the Provider Investigation Report dated 04/22/2024 indicated an allegation of neglect was reported to the state agency on 4/30/2024 regarding Resident #1 which was past the two hours required to submit an incident of alleged neglect. The cover sheet was addressed to the DADS Consumer Rights and Services agency. The incident occurred on 04/17/2024 at 3:44 p.m. The incident involved Resident #1's left hand and wrist, which was stuck in the wheel of his wheelchair, which resulted in a fracture. On 05/16/2024 at 3:45 p.m. interviewed the administrator, revealed that he was responsible for sending the reports to the CII provider number. The Administrator revealed that he may have sent the Page 1 of 2 455835 455835 05/16/2024 Interlochen Health and Rehabilitation Center 2645 West Randol Mill Rd Arlington, TX 76012

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provider Investigation Report to the wrong number. The Administrator did not have proof that he sent the Provider Investigation Report to the wrong number. The Administrator revealed that he must have forgot to send to the CII provider immediately after incident occurred. Record review of the facility's Abuse policy revised 03/29/2028 revealed in part: .it is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .injuries of unknown origin .and to ensure that all alleged violations .are reported immediately to the Administrator, DON and/or Abuse Prevention Coordinator .will also be reported to the HHSC . Review of Provider Letter PL 19-17, issued 07/10/19, revealed, .required reporting timeframes .neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that results in serious bodily injury .immediately, but not later than two hours after the incident occurs or is suspected . 455835 Page 2 of 2